Saving Children s Lives How to Reduce Childhood Deaths through Quality Improvement PRESENTED AT:

Saving Children s Lives How to Reduce Childhood Deaths through Quality Improvement PRESENTED AT:

Saving Children s Lives Reducing Infant and Child Mortality through Active In-Service Training, Quality Improvement and System Monitoring Peter Meaney, MD, MPH Christine Joyce, MD Jose Maria Ferrer, MD Segolame Setlhare, RN PRESENTED AT:

Objectives Review the essential components of Saving Children s Lives Discuss data regarding the impact of SCL on provider knowledge, patient outcomes and health system utilization Discuss next steps of Saving Children s Lives

The Challenge for Children On 58/195 Achieved MDG #4 2015 goal Top 10 causes of DALY include Lower Respiratory Infections and Diarrheal Disease Challenges with secondary prevention of major causes of child mortality ETAT and PALS in LMIC Designed for least resourced or most resourced implementation not as effective as could be Passive process Inadequate resources Health Access and Quality of Health Service Delivery is poor Health Access and Quality Index, Lancet Publication 2017

Model of Care of the Critically Ill Child Failure to Recognize Provider Knowledge Diagnostic Equipment Institutional Bias Individual Bias Failure to Recognize Provider Knowledge Diagnostic Equipment Institutional Bias Individual Bias District Hospital Home Clinic Primary Hospital A+E Ward Referral Failure to Treat Inadequate resources Location, supply, type Provider Knowledge/application

Saving Children s Lives High Intensity In-Service Training Active Audit and Feedback System Surveillance

Saving Children s Lives Pilot 2012: Modified PEARS to incorporate Hospital and National protocols 2013: Piloted at Referral (PMH) and District Hospital Feedback to better align better with IMCI teaching 61 Providers Demonstrated feasibility Wright SW, Resuscitation, June 2015.

District Next Level Steps Training Initiated January 2014 SLH, Kweneng Clinic and Hospital Based Providers Local Program Coordinator Program Metrics 28 Provider courses > 500 providers 5 Trainer of Trainer (TOT) programs 47 instructors Performance based, not administrative

Knowledge Acquisition Knowledge Acquisition Recognition of Respiratory distress 43% vs. 81%, p <0.001 Treatment of respiratory distress 51% vs. 77%, <0.001 Treatment of shock 18% vs.72%, <0.001 Improvements sustained up to 3 months after training. Percentage (%) 0 20 40 60 80 100 1st line Antibiotics Recognize correct sign Type of fluid Correct of fluid Pre-course Course Month 1 Month 3 Meaney PA, GH Symposium Abstract, Sep 2016.

SLH: Pediatric Ward Patient Outcomes 13 v 15 Significantly Lower (p<0.01): Admission Rates: 82 vs 61/month Total deaths: 27 v 9 deaths/yr Mortality rates 2.7% vs 1.64% Transfer rates 6.8% vs 5.2% No Significant Change length of stay (5.3 days vs 5.3 days). Meaney PA, GH Symposium Abstract, Sep 2016.

Infant Mortality (age 1mo 1year) 8.0% IPMS DATA, MOH, 2013-2015 8 of 13 District Hospitals Reporting Data 6.0% 4.0% 2.0% SLH: 57% Controls: 5.5%** 0.0% 2013 2015 Intervention district: larger volume of admissions at baseline, admission reduction vs no change compared to volume in controls

Next Steps: Study: Verify dataset is optimally complete (IPMS, Child Mortality) for formal analysis Identify potential sources of confounding during study period Add BID register data for deaths in community Administrative changes in intervention or control hospitals Differential rollout/penetration of national programs Validate findings through peer review process (publications) Scale Phased rollout for DHMTs with significant burden of amenable child mortality

Next Steps: SCL Global Broaden Global Steering Committee: Health System Leaders, USAID, Gates, ILCOR and Resus Councils, International Pediatric Association, KEMRI Revise program materials: Standardize active implementation - Allow for scalability in other health systems (TNZ, India): Increased audio/visual, mhealth, ehealth, remote telementoring Additional modules (neurologic, shock with malnutrition, trauma)

National SCL Program: Needs Needs from DHMT: Administrative leadership: Identification of training burden, integration with QI system, relevant stakeholders and issues Office/training space at District Hospital Transport to all participating clinics (monthly) Site Coordinators (2, 50% clinical, 1.0FTE total) Support for training equipment and consumables (e.g. books, manikins, lunches, IV tubing, pulseox) Imprest and Lodging for DHMT participants as appropriate Centralized support for continuous national program monitoring and development data management and reporting, logistics of training initiation and maintenance, site coordinator meetings

Conclusions Successful initial district level Implementation Validated relevance to system and clinical care 100% providers of target district trained in < 2yrs locally sustainable instructor core SCL Program implementation is associated with significant knowledge acquisition and retention of healthcare providers up to 3 months after training There may be an association between SCL and significant reductions in Neonatal, Infant, and Child Mortality in District Hospitals

Questions? Successful initial district level Implementation Validated relevance to system and clinical care 100% providers of target district trained in < 2yrs locally sustainable instructor core SCL Program implementation is associated with significant knowledge acquisition and retention of healthcare providers up to 3 months after training There may be an association between SCL and significant reductions in Neonatal, Infant, and Child Mortality in District Hospitals

Saving Thank Children s You! Lives Team